From Draft NOtices, January-March 2013

The Military Prepares for Warmaking but Not Its Medical Consequences

– Kathy Gilberd

Many observers say that the military medical system is broken. Military doctors and other medical professionals are too few to handle the multitude of physical and psychological illnesses and injuries engendered by two wars and other “engagements,” repeated deployments, and intense and rigorous training that injures many even before they are sent to combat zones. Soldiers are often denied access to medical care or pressured to avoid reporting injuries by military command units anxious to keep available troop numbers high. And recent changes to the medical discharge and retirement system, intended in part to speed processing of medical separations, have actually slowed the system down, with many ill or injured service members waiting well over a year to be retired or returned to duty.

The numbers of ill and injured troops from the Iraq and Afghanistan war are significantly higher than in past wars. Military officials are quick to attribute this to advanced life-saving techniques that leave more soldiers alive but injured. The intense pace of training, pressure to deploy soldiers despite medical problems that may worsen in combat zones, and repeated deployments (which similarly worsen illness and injuries) are also to blame. In some cases, soldiers with diagnoses preventing their deployment have found their physicians pressured to retract the diagnosis or replace it with one that permits deployment; in many other cases, military commands simply ignore doctors’ advice and regulations that would prevent deployment on medical grounds.

Ironically, these problems have continued despite repeated media exposés and some Congressional pressure. GI rights counselors and attorneys continue to see large numbers of ill and injured service members whose access to decent medical care is limited or nonexistent, and whose conditions worsen with continued service. Five years ago, a much-publicized scandal at the Walter Reed Army Hospital revealed that patients had difficulty navigating the medical system for care and medical retirement, often received poor or little care, and frequently lived in squalid housing for out-patients. Despite an overhaul of the system and its Wounded Warrior Transition Units, these problems remain. A recent GAO study, cited in Navy Times, noted that patients have difficulty getting into these units and have real problems “’navigating the recovery care continuum’ despite systemic changes that included new oversight committees and personnel hired specifically to help them.”

The common practice of denying access to medical care for all but the most severe and obvious injuries means that problems remain untreated until they reach such a level. This denial takes several forms. In some cases, supervisors simply refuse soldiers permission to make or keep medical appointments. In other cases, medics or GPs under-diagnose problems and send soldiers back to duty despite serious conditions warranting treatment and light duty. Throughout the service, a heavy stigma equating medical problems with weakness also keeps many soldiers from seeking help, for fear of harassment at their military command unit or harm to their careers. While this stigma is particularly strong for psychiatric illness, it applies as well to soldiers with physical injuries such as broken bones.

Those who do gain access to medical care find that the system is overloaded, so that appointments can take weeks to schedule, necessary tests can be postponed so long that they are eventually forgotten, and specialists are often unavailable. Pressured by heavy workloads and too many patients, doctors are not always able to give soldiers adequate time and attention, increasing the problem of misdiagnosis. Medical conditions are sometimes overlooked entirely by harried generalists and specialists who are too narrowly focused.

These problems are particularly true of psychological and neurological conditions. Post-Traumatic Stress Disorder (PTSD) and traumatic brain injury (TBI), called the “signature injuries” of the wars in Iraq and Afghanistan, are the most well-known of these problems, but soldiers in today’s military also experience depression, anxiety disorders and similar conditions in unprecedented numbers. A recent study found, for example, that hospitalization for psychiatric disorders accounted for 63% of the wartime increase in military hospitalizations. The study noted, “The predominance of these [psychiatric] causes of excess hospitalizations and hospital bed days is not surprising, because they directly reflect the natures, durations, and intensities of the combat in Afghanistan and Iraq, as well as the psychological stresses associated with prolonged and often repeated combat deployments.” And these conditions are among the least likely to be caught and treated early, given the particularly strong stigma attached to mental health problems and the fact that symptoms are often seen as lack of discipline or poor performance rather than indications of illness.

One of the most troubling results of military commands failing to recognize medical reasons for behavioral problems is that soldiers with serious psychological or even physical problems often face other-than-honorable administrative discharges for misconduct on the basis of symptoms of their illness. Soldiers with PTSD who are unable to control anger, service members with TBI who fail to remember orders and assignments, and personnel who self-medicate with alcohol or illegal drugs may face administrative discharge even when commands and military doctors are aware of their medical condition. In response to this problem, Congress recently enacted legislation requiring DoD to conduct specialized PTSD or TBI screening when combat soldiers facing such discharges assert that their medical problems may be the cause. A finding that PTSD or TBI is related to the “misconduct” will not halt the discharge proceedings, but it will be taken into account as mitigation regarding the character of discharge and possibly the discharge itself.

Earlier this year, troubling diagnostic practices at Madigan Army Hospital were brought to the public’s attention when someone leaked a psychiatric memo discussing the high cost of retiring soldiers with PTSD. On inquiry, media and interested members of Congress found that a special forensic psychiatric unit at Madigan was systematically reviewing PTSD diagnoses made at the hospital, and in many cases revising the diagnoses to other conditions not warranting medical benefits. An Army investigation of the problem has since led to the restoration of PTSD diagnoses for over 100 of the affected soldiers, and the Department of Defense has now agreed to make a wider investigation, across all the services, of handling of PTSD diagnoses.

Until about 2008, TBI, PTSD and similar psychological conditions were commonly under-diagnosed as personality disorders (PDs) by military psychiatrists and psychologists. Since PDs generally arise in adolescence, such a diagnosis can be considered a pre-existing condition that does not entitle soldiers to military or VA benefits for the illness. Furthermore, they are commonly viewed as behavioral problems rather than real illness, and so may be more stigmatizing than other mental conditions. Ironically, PDs are the only medical diagnoses actually mentioned on DD-214 discharge documents, adding to the stigmatization. Fortunately, exposure by veterans groups and the media brought this pattern of misdiagnosis to the attention of Congress, with the result that DoD is now required to screen members facing PD discharges for PTSD and TBI if they have previously been in combat.

One would hope that the problem would have ended here. Unfortunately, military psychiatrists who previously had a predilection for personality disorder discharges changed their preference within months of the new law, suddenly finding minor “adjustment disorders” rather than PDs in place of PTSD, TBI and other more serious conditions. While some of these disorders may entitle veterans to VA benefits, they are not a basis for medical discharge or retirement. Instead, soldiers diagnosed with problems like adjustment disorders may face administrative discharge without military medical benefits. Most recently, Congress has extended the requirement of special screening for PTSD and TBI to combat soldiers diagnosed with any mental condition warranting administrative discharge rather than medical retirement. It remains to be seen how the military will respond this time.

The result of these problems is a military rife with ill and injured soldiers pressed into combat or waiting in a kind of limbo for medical care and eventual medical retirement, and a generation of young veterans with illnesses and injuries that limit their ability to return to regular lives.

Commenting on the “Costs of War” study listed below, former Army epidemiologist Dr. Remington Nevin said that the figures on mental health problems “should have been apparent as early as 2006.” He added that “[t]he somber conclusions of this report stand in sharp contrast to the optimistic testimony offered by military officials throughout the first five years of war. A critical question civilian policy makers must now ask is why analysis similar to this was not published five or even six years earlier, when it could have aided health care planning efforts and informed a meaningful debate on the direction of the war.” The military’s failure to take into account and prepare for the medical consequences of the Iraq and Afghanistan wars and other military ventures is negligence at the very least. More likely, given the military’s tendency to create contingency plans for any conceivable war, it represents a decision to focus resources and funds on weapons and war-making capability rather than the medical needs of its own troops.